Provider Demographics
NPI:1710460407
Name:BERRY, CRYSTAL HUBBARD
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:HUBBARD
Last Name:BERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:548 OLLIE RD
Mailing Address - Street 2:
Mailing Address - City:PELION
Mailing Address - State:SC
Mailing Address - Zip Code:29123-9400
Mailing Address - Country:US
Mailing Address - Phone:803-397-1762
Mailing Address - Fax:
Practice Address - Street 1:107C VISTA OAKS DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-8230
Practice Address - Country:US
Practice Address - Phone:803-727-3882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health